Letter from academics concerned about the Cass Review

[MidsomerMurmurs]

Sally Hines et al have written a letter…
https://uncommon-scents.blogspot.com/2024/04/letter-from-academics-concerned-about.html?m=1

Worth a read, both for the quality of its argument and for the list of signatories.

https://twitter.com/lecanardnoir/status/1779535066944634919
When your letter against the Cass Review is signed by Andrew Wakefield, then some alarm bells ought to go off that you are on the wrong side

That appears to be a premium feature.

Also, “decades” divided by 97 is really not all that impressive, or what do they mean by “between us”?

@SnakesAndArrows in answering your question 'Is it that the alleged signatories do not understand that some studies - maybe ones carried out by my (or indeed Ben Goldacre’s) cat - are just not studies? Or are they saying the grading of the studies is invalid? Or that poor studies should be included and given as much weight as the good ones anyway??'

There is one other reason for academics disregarding/attempting to discredit that comes to mind - seeing the pre-print* from Dr Hane Muang mentioned above (link below) and consider some of the other Gender Critical academics listed, the Cass report will have set aside as unworthy/unreliable/unusable many sources that these researchers have created or cited, and based their own research on. As there seems to be a tenancy of circular citation this affects (I want to say infects) a lot of academic research in this area.

For example there is a table in Muang's paper showing the sources he drew on to justify claims that there was benefit and no overall harm (relative to no treatment) with PB and HRT. https://link.springer.com/article/10.1007/s11673-023-10313-z/tables/1 This lists 12 sources. Only five of these are mentioned in the Cass review and only two of that five were used by the York team. This is what the Cass review says about the other three...

Chen, et al. 2023
Prospective cohort study of 315 trans adolescents receiving HRT
15.40 The authors of a paper reporting on psychosocial outcomes of 315 young people treated with masculinising/feminising hormones (Chen et al., 2023) stated that the most common adverse event was suicidal ideation (11
participants [3.5%]) and two participants [0.6%] died by suicide. Suicidality at baseline was one of the exclusion criteria for this study.

'De Vries et al. (2014) is the original study of the Dutch protocol sample, which has marked differences to the population being treated currently, and as discussed had much stricter criteria for treatment.'

Kuper, et al. 2020
Prospective cohort study of 148 trans adolescents receiving PB and HRT
'Kuper et al. (2020) is a study with a one year follow up that showed very modest change. It fell into the group rated by the University of York research team as too low quality to be included in their synthesis of evidence on masculinising/feminising hormones (Taylor et al: M/F hormones).'

Muang's table summarises his very different take on the value of these sources

Chen, et al. 2023
'Trans adolescents who received HRT reported improvements in appearance congruence, affect, and life satisfaction, and decreases in depression and anxiety. HRT likely decreased depression and anxiety symptoms via the psychological mechanism of improving appearance congruence'.

de Vries, et al. 2014
'Trans people who received PB and HRT in adolescence reported improvements in psychological health and social well-being, including decreased depression and anxiety. Trans people who received PB and HRT in adolescence had similar levels of well-being to peers of similar ages from the general population.'

Kuper, et al. 2020
'Trans adolescents who received PB and HRT reported improvements in depression, anxiety, and body dissatisfaction.'

Gender academics researching in this area will not easily be brought to agree their source material and therefore their own research may be sub standard.

*Pre-prints are not accepted for publication yet (my understanding) so although Dr Muang's paper has 2000 views its not out of the woods yet (not fully reviewed). https://www.springer.com/gp/open-access/preprint-sharing/16718886

Gettingmadderallthetime - Thank you for this, it's very helpful.

And it's a clear demonstration of why there is a need for the Cochrane Handbook, so people can read and understand how to assess clinical evidence and why the methods, processes, and tools are standardised.

Even by the standards and comparative laxity of narrative reviews, that's a poor show from Muang. (Sometimes, a narrative review is the only option when there is a negligible evidence literature but this should be acknowledged in the review.)

Does this mean the Muang has (rather conveniently) already gifted us the opposite-world version of the Cass Review? Ie used the papers Cass discarded?

If so, a) I’m glad I chucked him into this thread and b) does this make Muang the AntiCass? 😁

(Now off to make sure Muang’s paper is internet archived!)

Not all journals do this but I deeply regret that there's no list of reviewers available to see who approved this paper and its assessments.

I have no doubt that Muang will have stiff competition for the crown of Anti-Cass, sadly.

@KellieJaysLapdog would not say anti-Cass but he works for GenderGP and according to LinkedIn has worked with them for 2 years and 4 months. The paper was submitted last year when he was working for them. I assume he made good use of GenderGP and their knowledge/connections to gather the more affirmative research. He may not have been aware of other research as he is a one man team (unlike Cass team which rigorously considered thousands of sources). So this brings us the strongest evidence.

His publication (assuming published in this form) would be cited and pointed to - so examining and finding out whether it stands up may be a bit of a pre-emptive strike if it does not bear scrutiny. This is the title in case people missed it. Gender Affirming Hormone Treatment for Trans Adolescents: A Four Principles Analysis It tries to show that there is no downside to this treatment and as you can see from that title its looking at research in the same narrow field as Cass has done.

Link to his article (I meant to put that in my longer post) https://link.springer.com/article/10.1007/s11673-023-10313-z

BTW I am not sure I have pre-print right. This may be the passed-review-published version. Does anyone know. Its not my field and I have been retired a decade now.

Academics do get a lot of unearned respect
I'd agree with that. I'm a specialist (not an academic but published by a serious press) in a small and arcane area, and the amount of utter bullshit tenured academics write about said area is mind-boggling. Some of it they could double-check via bloody Google.

Once upon a time I had great respect for academics. Now I have respect for those whose work appears to be solid and isn't full of samples of 4, or wild claims based on surveys, or glaring factual inaccuracies.

Are there many other areas where people fight so hard for less robust medical evidence? It smacks of 'shut up and let us do what we want' rather than 'provide the best possible healthcare, backed by evidence'. Bizarre.

It’s consistent with a world view that says your perception of the world is reality, and therefore any other view is based on someone else’s reality and both are equally valid. Except they shout louder so theirs is better. Or something.

Qualities such as objectivity, logic, evidence etc have no place in this world view, it’s all based on feelings and wants. I’m sure there’s probably a philosophical term for this but philosophy makes my head hurt. I like cold hard facts.

archive link for the text of Muang’s preprint

archive.is/VZZjm

archive link for Table 1:

archive.is/mVaRz

5 of Muang’s references are by Florence Ashley.

This Florence Ashley…

https://www.dailymail.co.uk/health/article-12969191/amp/Win-DM-com-World-Health-Organization-quietly-removes-transgender-extremist-panel-gender-dysphoria-story.html

afaict, it's a published paper.

Edited to avoid confusion.

My PhD was in the arts but in a field related to medical ethics, with a specific focus on forms of embodiment. Yes I am a Dr whose research tangentially touches on some of these issues, but I do not belong anywhere near these public debates. I actually recognise some of the people who have signed that letter, and they absolutely are not experts in this field. An arts PhD (which a lot of the people on that list have) does not make you an expert on evaluating the potential dangers and/or efficacy of puberty blockers on children. Leave that to the actual experts.

I would actually love to hear from surgeons and consultants on this. Not from academics in the arts or social sciences. If the review is wrong or was incorrectly researched, it's the surgeons and consultants who we need to hear from. Those on the front line of all this. I want to hear from people whose work goes beyond the theoretical.

An arts PhD (which a lot of the people on that list have) does not make you an expert on evaluating the potential dangers and/or efficacy of puberty blockers on children. Leave that to the actual experts.

And vice versa, please.

I liked this comment that Helen Joyce retweeted:

This is complete nonsense. I’m a biologist and I don’t go around telling you that you’re queering Jane Austen wrong or that you didn’t find enough heterocissuppression of marginalised voices in Teletubbies, so can you all stay in your lane

@NecessaryScene haha don't get me started on all the "queering" of everything, and I say that as a lesbian!

What's interesting about that list as well is that it includes PhD students and GTAs, so people who have not even completed their studies yet.

How many years of experience does Dr Cass have? Over 40 years of practice by my maths. But so and so working towards a non-medical PhD who has not even finished so much as a literature review yet knows better eh?

I mean anyone can write an open letter. Nothing wrong with that. The military wing of the united flower arrangers of Sutton Boggley can all write a strongly worded letter criticising Cass, if they like.

Doesn't mean anything.

https://x.com/saralikeclara/status/1779593226120216885

This is an area known as epistemic trespass.

"Epistemic trespassers are experts who pass judgment on questions in fields where they lack expertise. What's wrong with epistemic trespassing? I identify several limitations with a seminal analysis to isolate three desiderata on an answer to this question and motivate my own answer. An answer (i) should explain what's wrong in the cases that motivate inquiry into epistemic trespassing, (ii) should explain what's wrong with epistemic trespassing even if trespassers do not acknowledge their trespassing, and (iii) these explanations should not be independent of the fact that epistemic trespassing involves expertise. I also independently motivate a fourth desideratum: (iv) this account should explain the evaluative difference between different kinds of trespassing. To satisfy these desiderata, I develop a social analysis: epistemic trespassing is wrong because it is an abuse of expert authority that neglects novice vulnerabilities."

https://pubmed.ncbi.nlm.nih.gov/34024942/

I strongly agree that novices and people who've not performed due diligence may be classed as epistemic trespassers. Ballantyne lays out interesting arguments.

Nathan Ballantyne, Epistemic Trespassing, Mind, Volume 128, Issue 510, April 2019, Pages 367–395, https://doi.org/10.1093/mind/fzx042

https://philpapers.org/archive/BALET-2.pdf (accessible version above paper)

I'll go further and say that the harms of epistemic trespass in some spheres is rarely limited to the individual as it can harm other people. Bystanders may be led into error when they trust epistemic trespassers for whatever reason seems acceptable (outsourced thinking, lots of social support for an idea). Genuine experts can deplete precious, limited resources refuting the popularised errors of epistemic trespassers or leave it to PR campaigns to correct those errors (which may have limited success, look what's happened here with Cass).

However, people like Stephanie Davies-Arai have expertise in adjacent areas and have carried out analyses of the evidence that have effectively been formally confirmed by York and Cass. This is very much in lane for some people who have relevant research skills and knowledge. There is space for acknowledged autodidacts whose accuracy is verified by others.

This by no means exculpates Muang or others but it would be wrong to deride anyone as a commenter because so much of healthcare can now be beyond niche in its narrowness.

NB: it's can be wholly correct to roll eyes at people complaining about the make-up of the authorial line for systematic reviews. As people have pointed out, clinicians have done their bit in obtaining funds, running the trials in mandated phases, and publishing their results. For a systematic review and/or meta-analysis, you need trial methodologists, statisticians, information retrieval specialists, data analysts etc. - a multi-disciplinary team of people with relevant skills and expertise that they leverage for the review.

Exactly.

Just like there are excellent, good, adequate, bad, terrible etc medical doctors, the same goes for PhD doctors. Just because this list of signatories includes PhD's with questionable credentials, don't think that distinguishing between MDs and PhDs is a good way to identify those with quality thoughts. Your comment is also slightly offensive to the non-medical scientists doing scientifically robust research/work in this area that absolutely puts them in the 'expert' area.

It is absolutely reasonable to say that double-blind controlled trials are an impossible standard to asess some interventions. Double blind meaning neither the assessor not the patient knows what intervention they have had. So for a new drug treatment - placebo vs active drug - possible - so long as the patient cannot work out by the effects of the treatment whether they are on active or placebo treatment. If the active treatment causes you to develop a beard, cliteromegaly and a deep voice, then it's not double-blinded and so such a trial can never take place. That's not to say that decent trials with measurable outcomes cant and shouldnt be devised, just that they can never reach the holy grail of double-blind control. Lots of surgical interventions (eg amputation) cant be double-blinded, so evidence will be downgraded to weaker, but will still have meaning.

I'm a doctor and have written systematic reviews. I would not claim to understand review papers in unrelated fields - I could read a history paper but I'd have to go back to uni to know enough to critique it.

I work in a field with difficult to treat conditions and high risk therapies where we may say to someone - well we don't have any medicines licensed your condition, but we could try this immunosuppressant that sometimes works in a similar condition but has the risk of major side effects. I'd suggest that where I thought benefit was plausible and the risk of side effects was worth it (ie. life limiting condition and we have nothing else to try).

Gender dysphoria in children is reported to resolve in about 80% without treatment. No way would I suggest a high risk unlicensed treatment for a condition where around 80% of people see their symptoms resolve without treatment. The sensible approach is watch and wait.

I would be very, very surprised if an ethics committee allows a clinical trial of puberty blockers - their use on any basis for gender dysphoria is clearly wildly unethical.

Lucky offence is taken rather than given, eh?

It is absolutely reasonable to say that double-blind controlled trials are an impossible standard to asess some interventions. [...] Lots of surgical interventions (eg amputation) cant be double-blinded, so evidence will be downgraded to weaker, but will still have meaning.

Yes, you've found a grain of truth in the bald-faced lie:

It does not include a proper systematic literature review since it disregards most research evidence because it fails to reach the impossibly high bar of a double-blind trial.

The statement is a lie because the review did not disregard evidence for not meeting that bar. Even their screenshot (from the NICE review, not the Cass review) only shows papers being "downgraded 1 level", not "disregarded".

Yet more evidence (as if we needed it) that gender woo rots your brains. If I was asked to sign a letter such as this, my first question would be-am I qualified to give an informed opinion? If, as in this case, the specialism is medicine then a Phd in grievance studies or a diploma in interperative dance isn't going to cut it. Still, it gives a measure of how desperate the koolaid gang are becoming and we can expect to see three responses to Cass. 1-it wasn't me guv, I never said those things (otherwise known as the Hunt gambit). 2 keep shctum and hope it goes away. 3 go down with the ship whilst wearing full evening dress, which you have expressly donned for the purpose, which is what these fucking clowns are doing.

The Simonoff trial is under development and they mention the high bar for ethics approval.

A study into the potential benefits and harms of puberty suppressing hormones as a treatment option for children and young people with gender incongruence is being developed through the National Research Collaboration Programme (NCRP) in place between NHS England and the National Institute of Health and Care Research (NIHR). The NRCP joint programme provides a collaborative approach to study development; studies being progressed through this route still have to demonstrate that they can materially build the evidence base for potential future NHS treatment options, while meeting a high scientific bar in terms of research methodology, as well as securing other important research approvals, including ethics committee approval.
It is envisaged that children and young people in both England and Wales will be able to participate in the study with access through NHS children and young people’s gender services. A multi-disciplinary team approach will be taken to identify those children who, with the consent of their parents, may be deemed clinically suitable for consideration of puberty suppressing hormones through the study. Children participating in the study will also continue to receive comprehensive psychosocial support.
The study will measure a range of potential treatment benefits and harms (for example whether puberty suppressing hormones impact in a meaningful way on levels of anxiety or depression, on body image, or brain development) using a range of validated tools, questionnaires and user feedback. Key measures included in the study, and the way data are collected, will aim to bridge gaps in existing research and will also be shaped by engagement with a range of stakeholders, including children and young people referred into NHS gender services and their families or carers.
Professor Emily Simonoff has been confirmed as Chief Investigator for the study.

https://www.england.nhs.uk/commissioning/spec-services/npc-crg/gender-dysphoria-clinical-programme/implementing-advice-from-the-cass-review/cyp-gender-dysphoria-research-oversight-board/